Care Transitions The most interesting things happen in doorways --Inferno, Dan Brown An Under recognized Key to Improving Transitional Care: Feedback Loops Eric A. Coleman, MD, MPH But Dr. Coleman, we have done everything The Triple Aim through the Lens of Care Transitions Better health for populations self care as central tenet Better care for individuals quality and patient experience measures (HCAHPS/CTM) tied to value based purchasing Lower costs through improvement readmission penalties; STAR ratings, bundled payment, ACOs, MSPB and more A Word of Caution: Checklists and Task Completion in Context Ultimate Goal for Transitional Care To create a match between the individual s care needs and his or her care setting 1
Improving Cross-Setting Collaboration Loehrer S, McCarthy D, Coleman, EA Population Health Management DOI: 10.1089/pop.2015.0005 Effective Collaboration among Health Care Providers Requires: Trusted convener Common goals Shared understanding--site visits and shadowing Starting small and go after quick wins Data to identify opportunities for improvement Focus on patients needs and experiences Improving Cross-Setting Communication Loehrer S, McCarthy D, Coleman, EA Population Health Management DOI: 10.1089/pop.2015.0005 Design with the End-User (or Next-User) in Mind Put yourself in the shoes of the next care team Even better reach out and ask them! Think beyond your professional discipline Consider how data collection might serve multiple purposes for greatest efficiency Re-Thinking the Transfer (D/C) Form Include expectations for transfer what you hope or anticipate will be accomplished Shift perspective from historical to future Shift orientation from reporting versus action 2
Anticipatory Guidance for the Receiving Team You have done a great job of caring for this patients in the inpatient hospital bravo! Now we ask you to consult your crystal ball If something was going to go bump in the night(s) after discharge, what would that look like? What initial steps might you suggest to address the problem without sending to the ED? Carolinas HealthCare SNF Circle Back Questions 1. Did the patient arrive safely? 2. Did you find admission packet in order? 3. Were the medication orders correct? 4. Does the patient s presentation reflect the info you received? 5. Is patient and/or family satisfied with the transition from the hospital to your facility? 6. Have we provided you everything you need to provide excellent care to the patient? ]Source: Emily Skinner, Carolinas Healthcare System (HRET/HEN Website) Home Health Care Nurse Perspectives on Care Coordination for Recently Discharged Patients HHC nurses encounter many challenges including: 1) hospital & outpatient physician accountability 2) lack of access to hospital records, 3) difficulty reaching hospital & outpatient physicians 4) payer requires that HHC orders come from MDs 5) clinician misconceptions about HHC services. Patient Engagement Feedback Loops Christine D. Jones, MD, MS et al abstract presented at SHM 2016 Teach Back: A Core Competency Simulation to Road-Test the Care Plan 3
Do We Inadvertently Foster Dependency? Identifying when a patient crosses the invisible line Persons with Chronic Illness have Predictable Relapses of Their Condition Provide anticipatory guidance to person and family caregivers Use simulation principles to gauge selfcare capabilities of patients and family caregivers A Patient s Care Plan Is Our Best Guess The care plan is rarely customized to an individual s ability to participate in self-care What if we could road test the care plan before transfer? We could then refine and better customize the care plan JAMA 2014;311(3):243-244 4
Getting Started: A Simulation Lab.For Patients North Mississippi Health System Lee Greer, MD Opportunity to road test the discharge care plan for heart failure patients and modify based on performance Simulation lab in dedicated unit with multiple stations Reduction in 30-day readmission rate from 17% to 13% Meeting Patients Where They Are: The Care Transitions Intervention JCOM 2014;21(11):1-5 Key Elements of The Care Transitions Intervention Simplicity is biggest asset and liability Unique focus on skill transfer to support self-care Transitions Coach is the vehicle to build skills, confidence, provide tools all to support self-care Model behavior for how to handle common problems Practice or role-play next encounter www.caretransitions.org Coaching = Skill Transfer Coaching puts the patient in the driver s seat Agenda Is Driven by the Patient s Goals Doing for patient puts the patient in the back seat Educating puts the patient in the passenger s seat 5
Distinguishing CTI: What It Is and What It Is Not Care Transitions Intervention Results from the Real World What CTI Is What CTI Is Not Unique focus on skill transfer to CTI does not attempt to replace promote confidence in self-care home health care/case management Transitions Coaches have skills Transitions Coaches do not provide Tools to evaluate skill transfer skilled care Patient s goal drives agenda Coaches do not fix problems CTI aims to promote independence Coaches do not nudge or remind by not fixing problems for patients CTI has no checklists What Frightens Family Caregivers? Supporting the Unsung Heroes Family Caregivers The answer is many things However an underappreciated fear is that by not being adequately prepared, they may cause harm to their loved one Understanding the True Contributions of Family Caregivers Caregiver Advise Record & Enable (CARE) Act 46% family caregivers perform medical/nursing tasks 78% of family caregivers managed medications 53% of family caregivers served as care coordinators (1) Record family caregiver s name on admission; (2) Notify family caregiver when discharge is near; (3) Include family caregiver in discharge instruction Source: S. Reinhard, C. Levine, S. Samis. Home Alone: Family Caregivers Providing Complex Chronic Care AARP/UHF Publication October 2012. 6
39 States and Territories Have Enacted The CARE Act into Law: Alaska, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Hawaii, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, Texas, Utah, Virginia, Virgin Islands, West Virginia, Washington, Washington DC, Wyoming J Hosp Med July 5, 2016 Family Caregiver Activation in Transitions TM FCAT TM Tool The FCAT TM tool is designed to be administered by a health professional or self-administered by the family caregiver (takes 2 minutes) Facilitate more productive interactions and guide the care team in understanding patient and family needs and deploying appropriate resources Illustrative FCAT TM Items I have a trusted pharmacist or pharmacy in my community that I can contact if I have medication questions I understand which of the instructions in my loved one s care plan are most important and need to be completed first and which instructions are less urgent If my loved one needs help from a healthcare professional, I am confident I can insist until I get what is needed Risk Identification The Joint Commission Journal on Quality and Patient Safety. 2015;41(11):November:502-507. 7
What Predicts Execution of Discharge Instructions? Maybe it s not Mabel s heart that is responsible for her HF admits 1) Health literacy 2) Executive cognitive function 3) Activation/locus of control 3) American Journal of Medical Quality 28(5) 383 391 Hospital Admissions Risk Multiplier Screen (HARMS-8) 1. How would you rate your current health? 2. How many prescription medications are you taking? a) How often do you decide not to take your medications? b) How sure are you that you know the reason for taking meds? 3. Are you having any difficulty doing activities of daily living? 4. How often do you have trouble remembering or thinking clearly? 5. How many friends/relatives you could call on for help? 6. How confident are you that you can manage your conditions? 7. During the past 6 months, did you go to the emergency room? a) Do you think you will go to the emergency room again? 8. During the past 6 months, did you stay in the hospital? a) Do you think you will need to be hospitalized again? Consider a Two-Step Strategy Step 1: Narrow the population to a manageable # Predictive algorithm (e.g., LACE) Diagnosis (e.g. the 3 publicly reported) Prior utilization (e.g., Hospital, Obs and ED) Step 2: Go to the bedside Ask the patient to reflect on contributing factors Evaluate literacy, cognition, activation, family caregiver, mental health diagnoses Getting Started Getting Started: Consolidate Follow Up Phone Calls Getting Started: Community Transitions Conferences Patients may receive 4-6 follow up phone calls Confusing, frustrating, diminishes trust, disengage Ideally need to consolidate to a single professional with skills + accountability Marketing calls can wait a week or more Invite a broad array of stakeholders Have patients and families share their experiences Focus on poorly executed transitions Focus on well executed transitions Opportunity for constructive non-blaming discussion 8
Getting Started: Huddle for Care Huddle for Care is a virtual community of care transitions implementers exchanging innovations Browse stories of solutions implemented by transitional care teams across the U.S. http://huddleforcare.org/ We invite you to join us! www.caretransitions.org 9